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Health History and Lifestyle Form

This form and the information you provide will be kept in a manner that assures your confidentiality. Any information you provide will be available only to your trainer and will be used solely in conjunction with planning and developing health and fitness programs. so your coach knows how to best help you!

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Question 1 of 35

Name

    Question 2 of 35

     

    Select all areas affected by the issues listed below. Nothing is too small or too old to matter. Use the diagram above for visual reference.

     

    • Areas of acute or chronic pain

    • Scars

    • Tattoos

    • Accidents

    • Breaks/Sprains

    • Dental Work

    • Pregnancies

    • Head Trauma

     

    (Select all that apply)
    A

    Right Side of Face

    B

    Left Side of Face

    C

    Neck (front)

    D

    Clavicle (right)

    E

    Clavicle (left)

    F

    Ribs (right)

    G

    Ribs (left)

    H

    Abdomen (right)

    I

    Abdomen (left)

    J

    Right Hip

    K

    Left Hip

    L

    Groin

    M

    Bicep (right)

    N

    Forearm (front/right)

    O

    Right Hand (palm)

    P

    Bicep (left)

    Q

    Forearm (front/left)

    R

    Left Hand (palm)

    S

    Right Thigh (front)

    T

    Right Knee (front)

    U

    Right Shin

    V

    Right Ankle

    W

    Right Foot (top)

    X

    Left Thigh (front)

    Y

    Left Knee (front)

    Z

    Left Shin

    AA

    Left Ankle

    AB

    Left Foot (top)

    AC

    Left Side of Head

    AD

    Right Side of Head

    AE

    Back of Head (Left)

    AF

    Back of Head (right)

    AG

    Neck (back)

    AH

    Left Shoulder (back)

    AI

    Right Shoulder (back)

    AJ

    Upper Back (left)

    AK

    Upper Back (right)

    AL

    Low Back (left)

    AM

    Low Back (right)

    AN

    Left Glute

    AO

    Right Glute

    AP

    Tricep (left)

    AQ

    Forearm (back/left)

    AR

    Left Hand (back)

    AS

    Tricep (right)

    AT

    Forearm (back/right)

    AU

    Right Hand (back)

    AV

    Left Hamstring

    AW

    Left Knee (back)

    AX

    Left Calf

    AY

    Left Heel

    AZ

    Left Foot (bottom)

    BA

    Right Hamstring

    BB

    Right Knee (back)

    BC

    Right Calf

    BD

    Right Heel

    BE

    Right Foot (bottom)

    Question 3 of 35

    Please describe issues here.

    (Ex. 2013, broke left hand and chronic aching, suture scars.)

      Question 4 of 35

      Do you wear corrective lenses? If so, please describe correction.

        Question 5 of 35

        Have you had corrective optical surgery? If so, please describe.

          Question 6 of 35

          Have you had any major life changes in the last 6-12 months?

            Question 7 of 35

            Please check those that apply.

             

            (Select all that apply)
            A

            Shortness of Breath

            B

            Difficulty Focusing

            C

            Fatigue

            D

            PMS

            E

            Anxiety

            F

            Depression

            G

            PTS

            H

            Dizziness

            I

            Vertigo

            J

            Tinnitus

            K

            Headaches

            L

            Insomnia

            M

            Heart Disease

            N

            Blood Pressure

            O

            Chest Pain

            P

            Asthma / Lung Disease

            Q

            Thyroid Issue

            R

            High Cholesterol

            S

            Cancer

            T

            Allergies

            U

            Other

            Question 8 of 35

            If "Other," please describe.

              FUEL AND SUPPLEMENTS

              Question 10 of 35

              Please list all medications that you are currently taking and their purpose/diagnosis.

              (Include over the counter, prescription, and vitamin supplements.)

                Question 11 of 35

                Give me a bird's eye view on your current nutrition.

                (What, when, how do you eat?)

                  Question 12 of 35

                  How would you describe your relationship with food? 

                    EXERCISE

                    Question 14 of 35

                    What were your favorite activities as a child? 

                      Question 15 of 35

                      What is your favorite physical activity today? 

                        Question 16 of 35

                        What kind of strength, conditioning, or rehab exercises are you currently doing? (Detailed please!) 

                          Question 17 of 35

                          What barriers do you feel you need to overcome in order to be as healthy and strong as you can be? 

                            LIFESTYLE

                            Question 19 of 35

                            Profession and average work hours per week

                              Question 20 of 35

                              On average, how many hours do you sleep each night? 

                                Question 21 of 35

                                What do you do to relax/reduce stress? How often do you do this? 

                                  Question 22 of 35

                                  Do you/have you used tobacco?

                                  A

                                  Yes, I currently use tobacco.

                                  B

                                  Yes, I have used tobacco in the past.

                                  C

                                  No, I do not/have not used tobacco.

                                  Question 23 of 35

                                  How many alcoholic beverages do you consume per week, on average? 

                                    Question 24 of 35

                                    How would you rate your stress level, overall? (With 0 being none and 10 extremely high.)

                                    A

                                    0 (none)

                                    B

                                    1

                                    C

                                    2

                                    D

                                    3

                                    E

                                    4

                                    F

                                    5

                                    G

                                    6

                                    H

                                    7

                                    I

                                    8

                                    J

                                    9

                                    K

                                    10 (extremely high)

                                    GOALS AND BENCHMARKING

                                    Question 26 of 35

                                    PHYSICAL HEALTH

                                    Where are you going? What is your big, glowing dream? (Be specific.)

                                      Question 27 of 35

                                      PHYSICAL HEALTH

                                      What are 3 specific/measurable benchmarks that would indicate you've accomplished that dream?

                                        Question 28 of 35

                                        PHYSICAL HEALTH

                                        How do you feel about your journey toward those dreams? (1 being not satisfied at all, 10 being completely satisfied.)

                                        A

                                        1 (Not satisfied at all)

                                        B

                                        2

                                        C

                                        3

                                        D

                                        4

                                        E

                                        5

                                        F

                                        6

                                        G

                                        7

                                        H

                                        8

                                        I

                                        9

                                        J

                                        10 (completely satisfied)

                                        Question 29 of 35

                                        PHYSICAL HEALTH

                                        What habit do you feel is currently creating your trajectory?

                                          Question 30 of 35

                                          PHYSICAL HEALTH

                                          What support or change do you need in place that you have control over? (e.g. change in environment, social support, professional help, etc.)

                                            Question 31 of 35

                                            PHYSICAL HEALTH

                                            On a weekly or monthly basis, I'll know I'm on the right path if:

                                              Question 32 of 35

                                              Have you worked with a coach before? What worked for you? What didn't work for you? 

                                                Question 33 of 35

                                                What would you like me to know that I haven't asked? 

                                                  Question 34 of 35

                                                  I give my permission for my before/after photos and videos to be used in promotional materials.

                                                  A

                                                  Yes

                                                  B

                                                  No

                                                  Question 35 of 35

                                                  This form has been completed to the best of my knowledge and I will inform my coach of continuing health and lifestyle updates.

                                                  (Type your name.)

                                                    Confirm and Submit